Create 100 ATI NCLEX Exam Questions and Answers with Rationale From Chapter 10 to 15

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Sample questions from Create 100 ATI NCLEX Exam Questions and Answers with Rationale From Chapter 10 to 15

This material has 150 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, a 67-year-old client with heart failure has new confusion and cool, mottled hands; BP is 86/50 mm Hg, HR 122/min, RR 26/min, and SpO2 93% on 2 L/min by nasal cannula. Three other clients are stable. Which action should the charge nurse take first?

   • A.Call the provider after completing report on all four clients.
   • B.Ask the oncoming nurse to review the client's medication list before assessing the client.
   • C.Ask the nursing assistant to repeat the blood pressure in 15 minutes.
   • D.Assess the client immediately and activate the rapid response process according to facility policy.

   Rationale: New confusion, hypotension, tachycardia, and poor peripheral perfusion suggest acute deterioration requiring immediate assessment and escalation. Rechecking the blood pressure may provide useful data but must not delay action; completing report or reviewing medications first also delays response to possible shock. The exam takeaway is to prioritize an unstable client over routine handoff tasks.

2. 2.In the emergency department, a 54-year-old client being treated for a urinary infection becomes increasingly drowsy. At 0800, the client was alert with BP 118/72 mm Hg and HR 96/min; at 1000, the client is difficult to arouse, with BP 88/54 mm Hg, HR 126/min, RR 28/min, and SpO2 94% on room air. The client has received an IV antibiotic, and the next dose is due in 4 hours. Which actions should the nurse take now? Select all that apply.

   • A.Reassess airway, breathing, circulation, mental status, and perfusion promptly.
   • B.Wait for the next antibiotic dose to determine whether the client improves.
   • C.Activate the rapid response process or emergency escalation pathway.
   • D.Notify the provider of the acute change and report the vital-sign trend.
   • E.Delegate an unlicensed assistive personnel to independently assess the client's mental status.

   Rationale: The acute change in alertness with worsening hypotension, tachycardia, and tachypnea requires immediate escalation, focused reassessment, and prompt provider notification. Waiting for the next antibiotic dose delays care, and an unlicensed assistive personnel cannot independently perform a clinical assessment. The exam takeaway is that a deteriorating trend takes priority over scheduled treatment or delegated tasks.

3. 3.On a pediatric unit, a 7-year-old client with asthma is receiving scheduled nebulized medication. The client is alert, speaks in full sentences, and has an SpO2 of 97% on room air. Which task is appropriate for the registered nurse to delegate to an experienced licensed practical nurse (LPN)?

   • A.Evaluate whether the prescribed treatment plan has controlled the exacerbation.
   • B.Perform the initial respiratory assessment after the client reports new chest tightness.
   • C.Administer the scheduled nebulized medication and report the client's response.
   • D.Teach the caregiver how to recognize worsening asthma and use a written action plan.

   Rationale: For a stable client, administering a scheduled medication and reporting the response are tasks an LPN may perform within applicable policy and scope. Initial assessment, evaluation of the overall plan, and initial teaching require registered nurse judgment. The exam takeaway is to delegate predictable care while retaining assessment, teaching, and evaluation responsibilities.

4. 4.A 43-year-old client scheduled for an elective procedure tells the nurse in the preoperative area, 'I signed the form, but I do not understand what the surgeon plans to do.' The client is alert, and transport has arrived. What should the nurse do?

   • A.Pause transport and notify the surgeon that the client needs further explanation before proceeding.
   • B.Explain the procedure using the consent form, then send the client to the operating room.
   • C.Ask the client's spouse to explain the procedure because the client has already signed.
   • D.Ask the client to describe the procedure and sign a new consent form if the client agrees.

   Answer and rationale are in the full material.

5. 5.During a home visit, a 76-year-old client with chronic kidney disease shows the nurse a newly filled medication organizer. The client says, 'I put my old blood pressure pill in here too because I still have some.' The client reports light-headedness when standing; BP is 104/62 mm Hg sitting and 86/50 mm Hg standing. Which action is the priority?

   • A.Tell the client to stop all prescribed medications until the next clinic appointment.
   • B.Reconcile the medication list and contact the prescribing clinician or pharmacist about the duplicate medication and symptoms.
   • C.Document the client's preference and continue the home visit without further intervention.
   • D.Ask the client to take the remaining old tablets with food to prevent a missed dose.

   Answer and rationale are in the full material.